Knowledge Base Article

For most students, the school year has come to an end. However, for those of you that are involved in the Prior Authorization for Certain Hospital Outpatient Department (ODP) process at your hospital, there is some essential summer reading requirements that you need to complete in the next couple of weeks. p>

Background

This program was finalized in the Calendar Year (CY) 2020 Outpatient Prospective Payment System (OPPS) Final Rule and is specific to the Hospital Outpatient Department setting. Effective July 1, 2020, a Prior Authorization was required for the following five procedures:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

CMS believes this program will be an effective tool in controlling unnecessary increases in volume by ensuring payments are only being made for medically necessary services. You will find additional resource information and updates on the CMS webpage created for this program (link) .

2021 Program Updates

Two New Procedures to Require Prior Authorization

CMS has added Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to this process, effective July 1, 2021. These two services are not replacing, but are being added to the list of procedures currently requiring prior authorization.

Note: MACs will begin accepting Prior Authorization Requests (PARs) for these two new services on June 17, 2021, for services rendered on or after July 1, 2021.

February 26, 2021: Exemption(s)

CMS noted that “MACs are in the process of identifying those hospital OPDs that will be exempt from the prior authorization process. Starting February 1, 2021 MACs began calculating the affirmation rate of initial prior authorization requests submitted. Hospital OPD providers who met the affirmation rate threshold of 90% or greater will receive a written Notice of Exemption no later than March 1, 2021. Those hospital OPDs will be exempt from submitting prior authorization requests for dates of service beginning May 1, 2021.”

CMS’ Prior Authorization Program Operational Guide was updated on May 13, 2020. Updates are highlighted in red. There are a couple of specific updates to hospitals exempted from having to submit a Prior Authorization Request (PAR):

• The exemption will include PARs for the two new services being added to the program effective July 1, 2021.
• A word of caution, if you have been exempted from this process, you must continue to ensure documentation supports medical necessity of the procedure being performed. CMS has advised that they will be sending post-payment Additional Documentation Requests (ADRs) for a 10-claim sample from the time period you were exempted to determine compliance. Note, the sample may include claims for the two new services (cervical fusion with disc removal and implanted spinal neurostimulators).

May 13, 2021: Change to Implanted Spinal Neurostimulators

“CMS is temporarily removing CPT codes 63685 and 63688 from the list of OPD services that require prior authorization. The only service that will require prior authorization for implanted spinal neurostimulators is CPT code 63650. Providers who plan to perform both the trial and permanent implantation procedures using CPT code 63650 in the OPD will only require prior authorization for the trial procedure. When the trial is rendered in a setting other than the OPD, providers will need to request prior authorization for CPT code 63650 as part of the permanent implantation procedure in the hospital OPD.”

CMS has added the following paragraph to the program Operational Guide related to when a PAR is required:

“Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.”

May 14, 2021: MAC Educating Providers

CMS released Change Request (CR) 12214 (link) to instruct Medicare Administrative Contractors (MACs) to provide education regarding the prior authorization (PA) process for cervical fusion with disc removal and implanted spinal neurostimulators in the hospital OPD setting. One part of this education will be MACs sending introductory letters detailing the July 1, 2021 updates and general “What You Need to Know” information to physicians and providers. Templates of these letters are included in this CR.

Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators by the Numbers

In an effort to quantify the volume and payment related to the two new procedures, I worked with RealTime Medicare Data (RTMD). For those who may be new readers of our newsletter, RTMD’s current data base consists of Medicare Fee-for-Service paid claims data for hospital inpatient discharges, outpatient hospital services, and CMS 1500 professional services for 48 states and territories. The following data is specific to U.S. states for calendar years (CY) 2019 and 2020. Since COVID-19 had an impact on planned surgical procedures, I believe it is important to view both years of data

Cervical Fusion with Disc Removal

CY2019

• Procedure Volume: 20,203
• Paid Claims Amount: $163,592,946.40

CY2020

• Procedure Volume: 17,569
• Paid Claims Amount: $164,226,275.35

Implanted Spinal Neurostimulators

CY2019

• Procedure Volume: 27,056
• Paid Claims Amount: $43,991,713.02

CY2020

• Procedure Volume: 19,853
• Paid Claims Amount: $34,603,818.02

Moving Forward

This is where the urgent summer reading comes in. For those actively involved in this process, I encourage you:

• To read CMS’ OPD Operational Guide and Frequently Asked Questions, both of which were last updated on May 13, 2021,
• Review your MACs website for education offering related to updates to this program. You will find contact information for all of the MACs in the OPD Operational Guide.
• Make sure your Physicians performing these procedures are aware of the documentation requirements supporting medical necessity of the procedure. In addition to MAC contact information, the OPD Operational Guide includes “Required Documentation” for each of the procedure.
• Finally, if you are currently exempt from the PAR process, be on the lookout for ADR requests from your MAC in the not too distant future.